Healthcare Provider Details

I. General information

NPI: 1609205707
Provider Name (Legal Business Name): MAHILET SISAY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 W 23RD ST STE 130
ST LOUIS PARK MN
55416-1670
US

IV. Provider business mailing address

1375 DAVERN ST APT 408
SAINT PAUL MN
55116-2290
US

V. Phone/Fax

Practice location:
  • Phone: 952-345-3213
  • Fax:
Mailing address:
  • Phone: 651-925-9735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number10934
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberR 203829-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: